Agreements and Disclosures (6 Month Contract for Alumni)

Solutions Parenting Support

Agreements*

I authorize the Solutions Parenting Support, it’s employee’s and Independent Contractors to email any correspondence regarding my treatment, satisfaction with treatment, updates about my treatment and educational programs during and after the completion of my treatment to my provided email address.

I authorize the Solutions Parenting Support, it’s employee’s and Independent Contractors to collaborate with outside referral sources and outpatient therapists as documented onlyon the release of information form that I provide.

Disclosures*

I understand Solutions Parenting Support, it’s employee’s and Independent Contractors cannot be held responsible for being unable to access me due to telephone devices that may block their calls, my use of a pager system in which I cannot be directly reached, any form of caller identification, or any type of device that does not allow my parent coach to make direct telephone contact with me.

Financials*

The usual and customary rate for providing Alumni parent coaching services through Solutions Parenting Support. Please check the boxes to acknowledge the following terms:

Total charge $550

Services Included 1 scheduled parent coaching session per month for 6 months total

Additional Comments and Special Arrangements*

Please check the boxes to acknowledge the following terms:

The agreed upon rate will be paid in full and will be due prior to the initial monthly session.